KIDZ KONNEKT Consent Form

This consent form covers all youth club organised events, including residentials, conferences and day meetings. This form should be completed by a parent/guardian if you are under 18, before you are able to participate in any activities with the youth club. If you are 18 or over you should complete the form yourself and sign at the end of the second page. Failure to return a completed form means you will be unable to attend youth club and any events organised by the youth club.

Contact Details
Name of group leader: Hayley Vasey - Activities Officer Contact number: 07741637043 Alan Lonsdale Manager Contact Number: 07824883335
Child/Young Person Information (to be completed by parent/carer)
Name of child/young person:*
Parent/guardian name:*
Address:*
Address Line 1 Address Line 2 City County Post Code
Telephone:
Mobile:
Date of birth:*
Age:*
Emergency Contact
Name:*
Relationship to child:*
Telephone:
Mobile:
Medical Information
Name of doctor:*
Telephone:
Doctors address:*
Address Line 1 Address Line 2 City County Post Code
Does your son/daughter suffer from any conditions requiring special medical treatment, including medication? E.g. insulin, inhaler, tablets etc. If yes please give details below:
Does your son/daughter have any special dietary requirements? If yes, please give details:
Does your son/daughter have any special cultural requirements or lifestyle preferences? If yes please give details below:
Does your son/daughter have any known allergies? E.g. nuts, milk, chocolate, penicillin etc.
I DO / DO NOT give consent for a Kidz Konnekt’s representative to consent to medical or surgical treatment for my child on my behalf, should it be necessary.*
- I do
- I do not
I consent to my son/daughter taking part in all the activities they wish to participate in, including: arts and crafts, sports and games, computers, outdoor play, cooking, dance and drama and any extracurricular activities with prior notice.
- I consent to my son/daughter taking part in all the activities they wish to participate in, including: arts and crafts, sports and games, computers, outdoor play, cooking, dance and drama and any extracurricular activities with prior notice.
If there are any activities you DO NOT wish your child to participate in, YOU MUST inform a member of staff before they attend a session.
I acknowledge that I can request to see the risk assessment information and policies and procedures from the Service at any time.*
- I acknowledge that I can request to see the risk assessment information and policies and procedures from the Service at any time.
Responsibility for Child/Young Person Arriving/Departing Activity Sessions
I acknowledge that Kidz Konnekt staffs DO NOT have responsibility for my child prior to arrival or following departure from the activity sessions.*
- I acknowledge that Kidz Konnekt staffs DO NOT have responsibility for my child prior to arrival or following departure from the activity sessions.
Departure Information*
- My child will always be picked up by an appropriate person (unless I inform staff otherwise)
- OR I give permission for my child to leave unaccompanied (please tick as appropriate)
Photographic Consent and virtual activities
At times, photographs or video may be taken for promotional or publicity purposes. If you DO NOT wish your child to be photographed or videoed, YOU MUST inform a member of staff.
If you consent for your child to be photographed or videoed please tick here.
- If you consent for your child to be photographed or videoed please tick here.
My child Can be invited to and take part in on-line virtual activities organised by Kidz Konnekt
- My child Can be invited to and take part in on-line virtual activities organised by Kidz Konnekt
Declaration
I will support Kidz Konnekt with information about my child and families wellbeing should anyone have symptoms of a virus such as Covid 19, Flu, Chicken Pox, Measles, Sickness and/or diarrhoea Or any other illness I will inform staff and consider if my child should attend activities. I will support Kidz Konnekt to ensure my child’s consents to new harm reduction behaviour’s and social distancing to support the wellbeing of staff and other members.
Signed:*
Print name:*
Relationship to young person:*
Date*

KIDZ KONNEKT Consent Form

Contact Details

Child/Young Person Information (to be completed by parent/carer)

Emergency Contact

Medical Information

Responsibility for Child/Young Person Arriving/Departing Activity Sessions

Photographic Consent and virtual activities

Declaration

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KIDZ KONNEKT Consent Form

Contact Details

Child/Young Person Information (to be completed by parent/carer)

Emergency Contact

Medical Information

Responsibility for Child/Young Person Arriving/Departing Activity Sessions

Photographic Consent and virtual activities

Declaration

Events

Volunteer

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